New scientific discoveries are incredibly exciting, but often poorly understood and misused in dangerous ways.

Consider the discovery of radioactivity. It profoundly changed everything from medical imaging to nuclear power to atomic warfare. But before it was completely understood (no one knew it could lead to genetic mutations that result in cancer) it was misused in a variety of ways that range from humorous to horrifying.

…Once upon a time, radiation in different forms was new and wondrous and had a million uses -medications, cosmetics, industrial applications, and even entertainment. It was only later that the danger became evident.

These uses ranged from radioactive toothpaste, advertised as providing a bright smile and freshening your breath by killing bacteria in the mouth, to radioactive cosmetics to make your complexion “glow” and prevent aging, to patent medicines, to radioactive suppositories designed to deliver healthful radiation directly to internal organs. There is no way to know how many cases of cancer and how many deaths might have been caused by the enthusiastic adoption of radiation as a “cure.”

We appear to have learned nothing from that debacle even though the message could not be clearer: Do not implement new medical discoveries until they are thoroughly tested and understood. Indeed, we are eagerly rushing to repeat our mistake, only this time the scientific discovery is the microbiome.

The microbiome will likely turn out to be an exceedingly important factor in human health and disease, just as radiation turned out to be exceedingly important in health and disease (think radiology and treating cancer with radiation). But we are only on the cusp of understanding the microbiome, and therefore, capable of doing terrible harm by turning our speculations into action. That’s the theoretical reason why you shouldn’t believe what you read about the microbiome in the mainstream media, but there are practical reasons as well.

Consider that the micriobiome has its own microbiome, the virome, and it is the interaction between the bacteria and the viruses that prey on them and on human beings, that determines health and disease. There is a small, but growing body of evidence that the human body can harness or at least influence the composition of the virome in order to regulated the microbiome. A paper published last year in PNAS, Bacteriophage adhering to mucus provide a non–host-derived immunity, offers a tantalizing glimpse of the possibilities:

Mucosal surfaces are a main entry point for pathogens and the principal sites of defense against infection. Both bacteria and phage are associated with this mucus. Here we show that phage-to-bacteria ratios were increased, relative to the adjacent environment, on all mucosal surfaces sampled, ranging from cnidarians to humans. In vitro studies of tissue culture cells with and without surface mucus demonstrated that this increase in phage abundance is mucus dependent and protects the underlying epithelium from bacterial infection… Based on these observations, we present the bacteriophage adherence to mucus model that provides a ubiquitous, but non–host-derived, immunity applicable to mucosal surfaces. The model suggests that metazoan mucosal surfaces and phage coevolve to maintain phage adherence. This benefits the metazoan host by limiting mucosal bacteria, and benefits the phage through more frequent interactions with bacterial hosts. The relationships shown here suggest a symbiotic relationship between phage and metazoan hosts that provides a previously unrecognized antimicrobial defense that actively protects mucosal surfaces.

In other words, certain viruses help the body to fight off bacterial infections by killing the bacteria. Even more remarkable, it appears that the animal will change the composition of its mucous to recruit more of the helpful viruses and thereby make it easier to ward off infection by harmful bacteria. Moreover, research suggests that the virome differs far more from person to person than microbiome, suggesting that it may play a greater role in health and disease than the microbiome.

The bottom line is that the microbiome is extremely complex and interacts with the body and with both helpful and pathogenic bacteria in ways that we do not yet comprehend. That’s why any contemporary claims about the microbiome, including claims about possible differences in the microbiome of babies born by C-section vs. babies born by vaginal delivery are the intellectual equivalent of radioactive suppositories. We are dealing with something powerful, but we don’t know enough about it yet to make ANY recommendations since we have no idea of what the optimal microbiome looks like, of how the virome and the microbiome interact, of how the body uses the virome to manage the microbiome, whether individual differencess in the microbiome are clinically meaningful, and the long term effects of attempting to manipulate the microbiome.

The microbiome may well turn out to be as important as radioactivity. Only time, and much more study, will tell. Until then, we should be very careful about making any claims and promising any health benefits. As the example of radioactivity demonstrates, it is all too easy to do more harm then good by manipulating a system that is, as yet, poorly understood.

You say we should not implement new technology in the medical field before we completely understand how it works and to test it thoroughly. Yet you say people are idiots and neglectful if they skip routine ultrasound during pregnancy. Hmmm.

moto_librarian

Ultrasound has been around for quite some time, and has been proven to be safe for fetuses. I guess I don’t get your point, but with a name like “poop on dr bitch amy,” I don’t really want to understand your line of thinking.

poop on dr bitch amy

It takes about 100yrs for something to be proven safe. And no, it isn’t proven safe at all. There have been no human studies done on the safety of them, and both the FDA and the CDC admit to their risks and don’t recommend them to be used routinely. They are only for true emergency use.

(yes, I’m guilty of not reading my own links, but why does anyone make a claim that is so easily disproven?)

poop on dr bitch amy

i meant no long term studies, sorry. and those links state the risks and need for further research to fully understand the long term effects. Read your links.

Box of Salt

Read your own words.

You wrote “no human studies” – unqualified.

I’d also like to know where you got the idea that it takes 100 years to demonstrate safety.

I can think of several examples in which a new technology or intervention was demonstrated to be unsafe in much less time than that, without even looking things up.

Please do share your sources.

And thanks, now that I’m off work, I’m going to do some reading.

steve

The Author missing a very important distinction. That the microbiome was a certain way for a long time, and that we are destroying it with anti-bodies and anti bacterials. If I was to continue the radiation analogy. it would be like for all of history save the last 100ish years the earth bombarded us with radioactivity. 100 years ago we started to wear lead, and saw an increase in auto immune diseases, alergies, mood disorders, and obesity in the exact places that people wore lead.

Young CC Prof

To extend your analogy, let’s say this radiation killed half of all children before the age of five, left many of them blind or otherwise disabled, and frequently struck down adults in the prime of life with little warning. Few people exposed regularly survived to age 65.

Lead, or radiation?

Elizabeth A

Are you postulating that, for all of human history up until the last 100-ish years, the microbiome was the same in all places for all people? Because that seems incredibly unlikely to me.

In the 1600s, colonists arriving in Virginia from London didn’t know what clean water tasted like, and the people who lived in Virginia had never lived in close proximity to pigs or cows (which the Londoners all had). How could these two groups have possibly had similar microbiomes?

I suspect that we will eventually discover that many different microbiomes are functional. Different ones confer different advantages and raise different problems. And I suspect that how we’re born, and what we eat in infancy, is going to turn out to be the least of the issues affecting what purports to be a complex system.

Sarah

It’s exactly the same as Epigenetics- an amazing area that lay people have latched on to and completely misunderstood. And of course people are using their bad understanding to push their own agendas – ‘don’t eat this it changes the genome, but these vitamins etc’

Young CC Prof

Actually, I suspect diet is probably the biggest modifiable factor in your microbiome, a whole lot more important than anything that happened in infancy.

And of course, everything you eat affects your epigenetics. By drinking milk, for example, I keep active a bizarre recent mutation, the ability to digest lactose in adulthood. But the people who freak out about it, like you said, have no idea what epigenetics actually are, or about the fact that they change constantly.

Cobalt

And thank goodness for that particular mutation. Milk is one of my favorite things!

Sarah

Yep my point was that people are using Epigenetics the same way as the microbiome- to push their agenda

Insider

Published Monday, this research is an illustration of how our understanding of the microbiome (or microbiota) is incomplete and evolving (and it suggests that the claims of natural-childbirth advocates about the implications of C-section for the microbiome may be wrong):

Preemies’ gut bacteria may depend more on gestational age than environment
The researchers noted abrupt changes in each gut’s bacterial composition along the way to 36 weeks in gestational age but found that somehow the gut ecosystems adjusted and returned to what seemed to be a preordained progression of bacterial colonization.
What that means for preterm infants and how it might affect them in the long term are among questions raised by the new research, Warner and Tarr said.
“This is the largest and most intense sampling of newborn infant guts ever performed using modern sequencing technology, and we believe that the data from this study will be immensely helpful in understanding the human gut,” Tarr said. “It is our first glimpse of how these earliest in life bacterial colonizations — events that may have lifelong consequences — occur.”

Beth S

I just don’t understand jumping on the bandwagon when a discovery is new and “exciting” it’s like okay, so we’re just now understanding this, but we’re supposed to believe everything they say about it.
Now all the sudden, corn a staple of the American diet since the Native Americans were the only ones roaming the land, is at fault for every evil that comes around. All you have to do is just eat meat and veggies and your health will be perfect (Never mind grains have been a part of our diet since the earliest man walked the earth.) I’ve been told I’m a bad mother because when I buy Happy Meals I get my kiddos the fries because I don’t think everything they eat has to be healthy in order to have healthy kids.
So when I read about things like Microbiomes I’m odd enough to wait and watch for the evidence to come out before I make any sort of lifestyle change. Granted I like to think my lifestyle is pretty healthy and well rounded, but I’m sure somebody somewhere would find fault with it.

Sue

The microbiome, and specifically gut bacteria, have joined fructose-is-poison and paleo diets into the realm of pesudo-science quackery.

People seem to take isolated scientific facts, and misunderstand or misapply them, then end up with silly misinformation.

There is some evidence for faecal transplants from health people being of benefit in the specific condition of Pseuomembranous colitis caused by Clostridium difficile infection. Now, it’s being promoted as a ”wellness” treatment. Probiotics are thought to have some benefit to help restore a normal gut flora following antibiotics, but it generally self-restores anyway.

The infant gut flora is not stable until full solid feeding is established.

But let’s not let facts get in the way of making a buck. Why are people so suspicious of Big Pharma, but suspend disbelief when it comes to big sCAMa?

KarenJJ

“faecal transplants”… Sounds like a ton of fun…

Beth S

Please tell me that’s not what I think it is…

Nadia

It is exactly what you think it is.

Amy Tuteur, MD

“Nadia,” please do not keep changing your screen name. Go back to one of the names you used at the beginning. It is not fair to the other commentors for you to hide behind multiple names.

Mishimoo

Does it help to know that it was once a subject of discussion during lunch with my uncle?

Great post – it is shocking how very theoretical harms (ie. microbiome and bonding) are used to generate a great deal of fear while at the same time minimizing the fear of very real harms (brain damage, permanent disability).

Smoochagator

EXACTLY. This is what has me horrified by the tenets of NCB that I once swallowed hook, line, and sinker. The dangers of GBS and clotting disorders – which can KILL a newborn – are totally minimized and/or dismissed, and moms are told to refuse antibiotics in labor or the Vitamin K shot because they’re “unnecessary” and can “upset the newborn’s gut flora.”

Mishimoo

Somewhat OT:
Even though I have consulted Dr. Google, I was wondering if one of the GPs here could confirm that it’s mumps that presents as incredibly swollen glands, fever, lethargy, and ‘glue’ ear; not measles. I ruined family lunch on Sunday by disagreeing with my mother about whether my younger brother had mumps or measles while she was antivax. (I distinctly remember the symptoms because I was yelled at for not noticing the swollen glands and pointed that out, ‘ruining’ lunch) I just want to be sure that I’m right, because it’s still bugging me.

Sue

There is a big difference between mumps (swollen glands either side of the jaw) and measles (respiratory illness with red eyes and spotty rash).

Mumps is reasonably benign in girls but can cause orchitis (infection of testes) and infertility in boys.

Mishimoo

Thanks Sue! I don’t know if he had any problems with that, but I do remember him having to get tubes put into his ears to resolve his hearing issues.

Mumps was what Millicent had on The Brady Bunch when Bobby kissed her.

Or thought she had. I don’t think she actually had it, but she thought she might.

Mishimoo

Thanks Dr Kitty! She was insisting that the mumps symptoms were actually measles symptoms, and it was doing my head in.

Trixie

Very interesting post — two small typos in the second to last paragraph. There should be an S on “difference” and I think you mean “effects” with an E, not an A.

Amy Tuteur, MD

Thanks!

Liz Leyden

This may be OT, but does anyone else feel the same way about medical marijuana? With more states legalizing medical marijuana, plus wholesale marijuana legalization of in WA and CO, there has been a lot of evangelism and woo about it, but not much hard science.

I have no moral objections to marijuana use. However, if it is so beneficial to so many illnesses, from cancer to chronic pain, where are the studies? With variations between individual plants, how does a user know how much active ingredient they’re getting? What is an effective dose of THC? What is a toxic dose? How is ingestion via smoking or vaporizer differ from ingestion?

I’m a nurse, and what got me thinking about this was a discussion of nursing home residents using medical marijuana, and the nurse’s potential liability. On one hand, we can give meds with a doctor’s order, including supplements and homeopathic preparations. I had a resident who had an order for a daily cocktail. However, each medication and treatment had set doses, routes, expected effects, and potental side effects. For marijuana, it was “The doc sad it’s okay for them to toke up because it makes their (cancer, arthritis, depression) feel better ” It’s the difference between taking an opioid for pain and smoking opium for pain, or taking aspirin vs. chewing willow bark. Lots of woo, not enough science.

Mishimoo

I think that there needs to be more research into the use, contraindications, and side effects, because I think that it has potentially promising results from a few recent studies.

Having said that, I do think that the woo and the habitual users are ruining it for everyone with their behaviour/actions and lack of scientific support for their claims. I think that smoking/vaporising is an inefficient and somewhat unhealthy method of ingestion due to the tar content. I’m also concerned about the leftover fertiliser and pesticide residues from the growing method. Personally, I’d rather have the effective parts discovered, refined or synthesized, standardised and prescribed than just a script to smoke up as needed.

Beth S

They are it’s called Marinol and it’s basically the THC in a pill form. It’s been around for like ten years that I know of because my stepdad used to get it when he was going through cancer treatments.

Mishimoo

I hadn’t actually heard of this before, thanks for letting me know about it!

I still think there should be more research into the effects and usefulness of the various cannabinoids, because if something helpful is found, great! If not, then at least there would be more evidence to help people not fall into the woo. Plus, I’m selfish. I have a few medical conditions and I want as many decent medical options as possible should I reach a point where I can’t handle them with diet/exercise/rest any more.

Beth S

I understand what you’re saying, and for the most part I agree with it. I wasn’t trying to come off bitchy it’s just when people say it’s the THC that helps them and that you can only get that from pot is when I roll my eyes.
I agree there needs to be more research though.

Mishimoo

Oh, don’t worry, I’m the same. I just want to shake them sometimes because yeah, it’s a really interesting plant and there might be some cool stuff to help people in it BUT it needs to be properly researched first.

Plus there’s the whole “it cleans the dirt it’s planted in!” aspect that a lot of people don’t think through fully. If it’s really cleaning the dirt by sucking heavy metals and other contaminants out of it, where do they think those chemicals go? Into thin air or something?

araikwao

There has been a lot here(Australia) in the media a bout parents using cannabis oil for their young kids with intractable epilepsy. It is not legal, so cue all the dramatc police investigations documented on current affairs programs. However, its use for this purpose has popped up frequently enough in journals recently as well , with some impressive results in case studies, such that it is probably time for some proper trials, IMHO.

Sue

Yes! The proposal for medically-prescribed marijuana to assist with symptom control in Oncology has morphed into cannabis oil being a miracle cure for everything.

As a general rule, the more diverse conditions a substances is claimed to cure, the less likely it is to cure anything!

THC definitely has pharmacological effects – both some anti-nausea but also causes cyclical vomiting in excessive users.

I don’t have too many issues about use at the end of life, even just to be ”spaced out” if the alternative is some other sedative drug. That doesn’t make it a cure-all. And the daily cocktail sounds perfectly civilised – I’ve never understood why we expect the elderly to be abstinent in their own residential setting.

Cobalt

I think medicinal marijuana, in most of of it’s touted applications, is a load of crap. There are generally way more effective therapies, with fewer side effects and no second hand smoke. Like the comparison with willow bark instead of aspirin, you need to take so much that the side effects vastly overshadow the benefits and getting a standard dose is nearly impossible. I’m sure there are exceptions that exist, just like with any drug, there will be those people with atypical reactions who really will benefit more from marijuana than current treatments. But it’s not magic and it’s not good medicine.

A lot of the support is from recreational users trying to destigmatize their preferences and make it a legal recreational choice, or from dealers wanting to make money. Whether they should be successful is a separate issue, I personally think it’s really not worth it to society to keep marijuana illegal.

Beth S

Medical Marijuana is as much a load of crap as the homeopathic, naturopathic medications people turn to today. Are there times when it helps people, sure, however the THC which is what supposedly helps people through these illnesses already comes in a pill form, it’s called Marinol and I’ve seen it given to cancer patients, hepatitis C patients, etc…
I have no problem if people want to toke up, but they need to be honest about why they’re doing it, and that’s to get high. Many drugs that we consider dangerous today started out with medicinal purposes, heroin started out as a cough syrup, cocaine as a headache medication, and LSD as a cure for mental illness. As we understood more and more about the devastating effects of the addictions to these drugs they became illegal.
So my question is why legalization advocates have made marijuana their hill to die on when it comes in pill form? Especially when you consider that pill form comes without the exposure to second hand smoke to the general population, as well as the exposure to whatever toxins or additives the dealer has decided to mix in with their product.

lawyer jane

Anecdotally, I know at least one person who got significant relief from the horrible pain of ulcerative colitis by smoking just a small amount of marijuana every few days. I can believe that Marinol is not as efficient/does not have the same compounds as whole marijuana. That said, I bet 95% of people using medical marijuana are really just recreational users. There’s also evidence that psilocybin mushrooms can help with cluster headaches – if you’ve ever known anyone who gets clusters, then you know that any kind of treatment that works has strong justification! I certainly don’t blame someone suffering from a painful condition for using these remedies without proof in the form of a double blind study.

The Bofa, Being of the Sofa

I’ve said it many times before. The problem with the medical marijuana (and before that the hemp movement) is not the pot, it’s the advocates.

This was especially true in the hemp movement. Am I supposed to think that Woody Harrelson is really concerned about the potential economic benefits of hemp materials? Or is he just a stoner who is trying to use hemp as an excuse to get pot legalized?

I would be a much better spokesman for the legalization of medical marijuana or hemp, having never toked up. However, I don’t give a rat’s butt about hemp and my advocacy of medical marijuana is limited to uses where it could be useful. I’m all for opening up the investigation of possible uses, but from a scientific perspective. Hence, you need things like plausibility. Running around and testing the use of pot for the treatment of everything or another is as much a waste of resources as doing it with anything else.

Allie P

I’d so much rather have been born via c-section and have a potentially faulty “microbiome” than not be born by c-section and be dead, maimed, or brain damaged. Am I alone here?

Mishimoo

Nope! Despite everything, I’m pretty happy to be alive thanks to being born by caesarean.

AccieCat

Right, a “healthy mucosal system.” So that means do what you need to do to help encourage a healthy mucosal system like: have a low-trauma and least stressful birth that doesn’t hammer the baby’s immune system from the start, I’d say that includes a medically appropriate birth at a medically appropriate center with adequate appropriate and responsible prenatal care.
When I had gone through 3 surgeries and multiple antibiotics for sinus infections and developed a resistant strain my ENT Surgeon suggested that we go old school. He had a compounding pharmacy mix up a antibiotic/steroid nasal rinse, ordered me to get a nasal irrigation system and start physically washing out my nasal passages 2 times a day. As well as get on adequate allergy treatments. Wow, it worked. it’s been 11 years since a serious sinus infection. Sorry, I went way off topic there but, it fits in with the discussion on anti-biotic use, and mucous membranes so, there’s that.

Amy

I really loved this post!

Mishimoo

Same! Science is just so cool.

Are you nuts

Entries like this remind me that I am a finance major. I had to “google” microbiome.

Smoochagator

I’m an artist. I like the science but I need it explained very slowly with very small words.

Young CC Prof

Count yourself lucky.

RNMomma

Thank you for this.

attitude devant

A physicist friend and I went hiking this week, and we just got hysterical giggling over all the bits of science that have been hijacked by quacks over the years. In the tradition of the creators of Teenage Mutant Ninja Turtles, we tried to create an amalgam of all of them, so that we could package our own woo. We came up with HVQHE: Holistic Vibrational Quantum Homeopathic Essential oils (that fact that this phrase is internally contradictory on multiple counts was part of the fun). Now I’m going to have work the microbiome into it. Hmmm.

From the website – “The liquid Crystals (TLC) are geometric vibrational remedies made from the Earths Metals, Minerals and Crystals. They are change facilitators, healing Spiritual, Emotional, Mental and thus Physical imbalance.

The Liquid Crystals are created via an ancient remembered process that embraces Crystalline Integrity, Sacred Geometry, Alchemy, Solar, Luna and Universal energy. The Liquid Crystals have returned to facilitate our planet back to Oneness by Reuniting the Crystalline grids, Above, Below and within Humanity.”

KarenJJ

Sounds like some that should be in a computer screen.

attitude devant

My goodness. I bow my head in awe before such erudite inanity. I am try not worthy to inhabit the same MLM pyramid.

Oh Good God. Fluoroscopy no less!!!!? The most radiation intensive of all imaging modalities? Great.

Ash

If these studies don’t already exist, I suspect there will be data published that interventional radiologists&interventional nephrologists have a higher rate of carcinomas on their hands than the general population. I see their hands under the fluoroscope sans lead protection.

attitude devant

Umm…I think, but could be wrong, that there IS a higher risk of leukemia/lymphoma. Anyone?

araikwao

I think there is some concern about cardiologists and all the stents et al, too..

Empliau

I read somewhere (maybe even on the internet so it must be true!) that there were higher incidences of cancer in people who worked in shoe stores during the heyday of these devices.

Trixie

My mom was born in 1954 and remembers them using these.

Liz Leyden

My father, born in 1945, mentioned foot x-rays in stores.

Young CC Prof

Yeah, that’s kind of what I think about the microbiome. We know it’s important. There’s solid data linking microbiome issues to a few things (C. Diff, yeast infections, certain vitamin deficiencies) and preliminary data linking it to everything but the kitchen sink.

The idea that antibiotics kill off good bacteria along with bad ones is pretty well established, and yes, some antibiotic prescriptions are unnecessary. (Doctors should stop prescribing antibiotics they know are unnecessary, patients should stop asking for and expecting antibiotics for every little cough. Everyone agrees on this, but overuse continues.)

However. We don’t really know what a “healthy” human microbiome looks like. It’s probably as open to variation as a “healthy” diet, but we don’t know what normal variations are, and what variations are harmful. I would imagine there are a lot of tradeoffs involved, that a particular type of organism protects against THIS illness but increases the risk of THAT one.

Most of all, just because something changes the microbiome, that does not necessarily mean that the change is for the worse.

The Bofa, Being of the Sofa

(Doctors should stop prescribing antibiotics they know are unnecessary, patients should stop asking for and expecting antibiotics for every little cough. Everyone agrees on this, but overuse continues.)

I know it’s OT, but to an extent, this is basically the same problems with unnecessary c-sections. We know that we do c-sections in cases where they would not need to be done, but the harder question is, who got a c-section that should not have based on the information at the time?

Same with antibiotics. I know that it’s easy to say that “patients ask for them for every cough”*** and “doctors hand them out like candy” but I don’t think that is near as common as suggested, and not near as much as before. The problem is, when a 2 yo comes in sick with an ear infection, do you treat it and take the chance it is bacterial? Or do you just let them suffer on the grounds it could be a viral infection? As a parent, I like to take the chance that we can clear it up quickly.

Our older guy had maybe 10 ear infections over the years. Of those, there was only one that didn’t immediately respond to antibiotics (as in by that first night), and took another day or so. That might have been a viral bug, and do maybe antibiotics were unnecessary. However, the rest of them were clearly bacterial infections. What should we have done? Not treated him? Of course not. But it still meant a case of unnecessary antibiotics.

***My wife was struggling with a lingering cough late last week, and was complaining that she might have to get it checked out because it just wasn’t going away. She happened to take an antibiotic Saturday night for an unrelated issue, and, viola, her cough cleared right away, and she completely perked up!

Young CC Prof

The difference is that in this case it’s the infectious disease experts afraid of too many antibiotics and patients asking for more and more. Those ear infections that clear up a few hours after the antibiotics also clear up a few hours after no antibiotics, for example. There are very few surgeries that are unnecessary, but lots of antibiotic prescriptions that are.

Heck, I’ve repeatedly turned down unnecessary antibiotics, and the one time I didn’t, I regretted it.

The Bofa, Being of the Sofa

Those ear infections that clear up a few hours after the antibiotics also clear up a few hours after no antibiotics, for example.

SOME do, but some don’t.

If half of them would and half wouldn’t, do we not treat the ones we can because there are some we don’t need to?

Young CC Prof

Actually, studies show that children given antibiotics vs not given antibiotics recovered equally quickly. What they recommend now is give the prescription, but wait a day to fill it.

lawyer jane

My son had a horrible allergic reaction to penicillin for an ear infection, so now we use the wait-and-see approach because we have seen first hand the possible side effects. The APA actually outlines the criteria fairly clearly for when to give antibiotics. The watchful waiting approach requires multiple visits to the ped, but it’s worth it to us. Unlike a breech c-section, failing to treat a bacterial ear infection for a few days has much lower risks!! (Although, it is true that children used to die of ear infections.)

What has actually been more difficult than ear infections has been possible bacterial pneumonia. There are not good guidelines for that, so we’ve ended up doing antibiotics a few times when the doctor thought his lungs sounded too crackly. But now that my son is older and more robust, we’ll probably delay abx a day or two even in those cases.

Young CC Prof

That’s a good point. When a baby is in the breech presentation, there is a 5% chance that labor will end in head entrapment. Once head entrapment occurs, it’s too late to go back and do a c-section.

If a normal person is mildly ill with something that might, but probably won’t, require antibiotics, waiting and seeing for a day or two is extremely unlikely to result in serious harm.

And yes, I’ve had allergic reactions to about half the antibiotics I’ve ever had, so every time I’m prescribed antibiotics, I say, “Is this worth my possibly losing access to an entire class of drugs forever? What if I did get pneumonia and there were no options left?” For someone else, with no drug allergies and a tendency to get bad infections, obviously the equations are very different.

Theoneandonly

Completely OT: My brother died as a result of an antibiotic resistant infection. He contracted meningicoccal septicaemia, and while he was in intensive care he contracted 3 major infections (along with other associated problems that come from contacting this disease). The first resulted in his legs being amputated at the knee, the second his arms being amputated just below the shoulder, and the last…there were 2 known antibiotics to treat this particular infection – he was allergic to one antibiotic, the other was resistant. Apparrantly his doctors spent all his last day combing the Internet and contacting doctors internationally to try to find a new treatment.

Mel

I’m so sorry.

Theoneandonly

I’m sorry for your loss too Mel.

Medwife

Except it is not OT at all. Inappropriately prescribed antibiotics lead straight to resistant bacteria. I mean, even appropriately prescribed antibiotics do, so use really truly should be restricted to situations where there are significant signs of the bacterial illness. Or as post exposure prophylaxis to very dangerous illnesses.

I’m very sorry about your brother. It sounds like everyone fought very hard for him.

Theoneandonly

I meant OT from the original post – but point taken

Thank you for your condolences.

Mishimoo

I’m so sorry for your loss.

Mel

My brother was one of the extremely rare kids who died of an ear infection. Nowadays, it requires the unlikely combination of an extremely faulty immune system AND no previous signs of the faulty immune system.

Guess what my parents did when we got ear infections as kids – and me as an 18 year-old – even after David died? We waited a few days. The rest of us had normal, robust immune systems AND they have those amazing prescription ear drops that numb the pain. I love those.

Tip from an adult ear infection survivor: Get the ear drops because the pain is awful. The drops sting a bit when they touch the eardrum because the liquid is cold, but I found that if I put the vial in my pocket or bra for 15 minutes or so before applying the liquid, there was no pain at all because the liquid was pretty close to body temperature. I do the same for my semi-annual pink-eye drops.

Liz Leyden

If your son is allergic to penicillin, the reaction would’ve occurred whether or not the infection was bacterial.

Staceyjw

Yes, my DD had a nasty case of pneumonia that sent her to the hospital. They thought she had bacterial, and gave her abx. Her fever was so high, she was doing so poorly, it was worth it. Once the culture came back, and it was viral, they stopped the abx and switched to just supportive measures. She had it for over 2 weeks.

My Ds and DH also has this pneumonia, Ds for 5 days, only one spent feeling sick. DH had it 2 weeks, and was in bed for a week. I never got it, but I did get the vaxx.

Liz Leyden

Bacterial infections resolve more rapidly when treated with antibiotics.

“Results from a randomized, placebo-controlled study indicate that
antimicrobial treatment of AOM-related middle ear effusion is effective
even in older children. In the Finnish study, of 84 children aged 6
months to 15 years, 50% of the patients were treated with antibiotics,
with middle ear effusion resolving an average of 2 weeks earlier in
these children than it did in patients who did not receive antibiotics.
Reduction of mean duration of ear effusion by age was as follows[1, 2] :

Many ear infections are viral. It is difficult to tell the difference initially.

DiomedesV

And… I see my post is redundant.

KarenJJ

That’s what we’ve been getting. My eldest is prone to ear infections and is also on an immunolsuppressant medication so her doctor is a little more cautious to keep on top of infections then otherwise.

DiomedesV

C-sections affect the mother and baby of that case only. The overuse of antibiotics affects the family members of the person taking them (because their microbe diversity declines as well) as well as society as a whole. Aside from the fact that both are interventions that have NNTs as all interventions do, they are not broadly comparable.

Visiting the pediatrician regularly to see how the ear infection is proceeding is costly in terms of time and money, but long term, it exacts a smaller cost on society in terms of drugs that are no longer effective.

Not to mention that antibiotics have side effects, which can be very unpleasant. Is it worth it to get rid of the ear pain if you have a kid with diarrhea for the next week?

Guestll

My daughter has a great pediatrician. She has also had ear infections on and off since the age of 9 months. She’s 3 now and hasn’t had one in about six months. Anyway, after age 2, he stopped prescribing antibiotics for ears. We treated with ibuprofen for pain. We didn’t do tubes, he felt she’d outgrow the infections, and he hesitates before recommending surgery. After a few days of no abx/ibruprofen, we’d revisit and get her ears checked again. This protocol worked well for us. I’d rather have an extra visit or two and do watchful waiting/pain management, rather then take yet another round of antibiotics to cure something that will eventually go away on its own.

Sonia

Long time lurker, but I had to ask – how does one person taking an antibiotic lower the microbial diversity of family members?

Young CC Prof

Family members share bacteria all the time. Most of the time, this doesn’t result in infections, but if one family member has a resistant infection, sometimes you need to see what’s going on with the others. People who just harbor MRSA all the time often have family members who are also colonized with MRSA.

Sonia

I get that – I’m a microbiologist. What I’m not clear on though is Diomedes V’s comment that ‘The overuse of antibiotics affects the family members of the person taking them (because their microbe diversity declines as well)’. If I’m on antibiotics, how does that impact my husbands normal microbiota?

Liz Leyden

Right now there is no way to culture the fluid to tell if the infection is bacterial or viral, unless the child has ear tubes. The same problem exists with sinus infections; color alone is not a sign of a viral vs. bacterial infection. Until someone develops a rapid test for sinus infections (like the rapid Strep test for throat infections), watchful waiting is the only way to tell a viral infection from a bacterial one.

The Bofa, Being of the Sofa

There are very few surgeries that are unnecessary,

But that’s not true. 95% of c-sections for breech babies are unnecessary, for example, in the sense that they could be delivered successfully without a c-section.

The problem is not that they are needed, but that we don’t know ahead of time which ones will be successful and which ones won’t, so we do them just to err on the safe side.

Young CC Prof

Sorry, I’m using a different definition of “Unnecessary.” Surgeries are generally done only when, based on the best information available and a comparison of the probabilities of different outcomes, the benefits outweigh the risks.

I do believe that a significant portion of antibiotic usage fails that test. Antibiotics are used to treat conditions which are probably viral and have a very low probability of progressing to a serious condition anytime soon.

Now, sometimes just-in-case antibiotics make sense. Surgical prophylaxis, sure. If someone is immunosuppressed or has a history of dangerous infections, it makes sense to hit hard at the first sign of trouble. If I had recent close contact with someone who was just diagnosed with bacterial meningitis, please bring me rifampin!

But for an earache in a healthy child over 1 year, or for a cough in a healthy school-aged child or adult, the short-term side effects and long-term risks outweigh the possibility that antibiotics could speed up recovery a little bit and the remote chance of the infection progressing. (If it doesn’t clear up in a timely manner, THEN bring out the antibiotics.)

For one thing, overuse is selfish. Antibiotics are a finite resource, at the individual, community and global level. A dose that could save a life shouldn’t be wasted on someone whose life is in no danger. Also, it’s short-sighted. The more antibiotics you take, the more you personally are at risk of a resistant infection.

And then we get into the truly stupid use, like acne treatment.

moto_librarian

IIRC, there are guidelines regarding how to treat ear infections in children that have changed over time. Our older son had repetitive ear infections that resulted in high fevers and sheer misery. Because he was less than two and running a fever, antibiotics were the treatment. By the time he was ten months old, his pediatrician was convinced that his left ear was never free from infection, and she sent us to an ENT. To stop the cycle of oral antibiotics and infection, the surgeon placed ear tubes. When he briefed us after the procedure, he noted that our son’s left ear had pus-filled fluid in it that had to be suctioned out, which meant that his pediatrician’s conclusion was correct. At almost five years old, he seems to have outgrown the problem, and has not taken antibiotics in three years. While I did not relish the idea of putting my baby under general, I also did not want to have to continually subject him to antibiotics that were not able to clear out the infection.

AccieCat

The only time we insisted on antibiotics for an ear infection was when there was also green snot, and we were facing a long weekend or holiday. No one wants to have to go to the ER or call the on-call Doc in those cases. We usually never had to fill it, but the few times we did it was inevitably at 2 in the morning, on vacation, in another state. Ugh.

Especially when your baby eats peas. (HOW does it get up his nose EVERY time?)

DiomedesV

As long as the patient doesn’t immediately fill and use the antibiotic, it may be more cost-effective to give them the prescription so they can feel more comfortable waiting until Monday to see their pediatrician. After one subpar experience taking a baby to urgent care, and having discussed it with a couple of pediatricians, if I’m concerned enough about my kid over the weekend that means we’re going to ER. Which is almost surely going to end up being a waste of everyone’s time and money. I’ve taken her to the doctor several times late Friday when I thought she was probably going to be OK just to avoid that scenario.

Sue

True – green can mean lots of eosinophils (allergy, hay fever). Drying-up-snot therapy often helps comfort, as well as yuck-factor!

araikwao

If you delve a little into orthopaedic surgery outcomes, there is rather a lot of unnecessary surgery going on. Dr Skeptic has a good blog about this which I haven’t checked for a while, hmmm…back soon!

Mishimoo

My husband’s step-sister is having a procedure done soon which sounds pretty cool. They’re taking fat cells from her torso, modifying them, and then injecting them into her knee to hopefully help repair it. (Trying to avoid a knee replacement)

Mishimoo

My cousin died after developing a VRE infection after some surgical mishaps. It’s part of why I try not to contribute to the development of resistant-strains by avoiding antibiotics unless they’re needed. I’ve been lucky though and not really needed them. My kids don’t get sick like I did when I was their age, and I don’t get sick like I used to. My dude doesn’t really catch anything either, despite working with the public.

I’m actually pretty amazed, there have been times where we’ve gone to the doctor for a check-up or for their vaccinations, and the doctor has said “Oh, they’ve had an ear infection recently. Looks like it’s resolved well.” and the only outward sign of it was a mildly grizzly kid that felt nauseous and had a low-grade fever for ~24 hours. I was expecting them to be like my siblings: miserable, terribly sick, and eventually needing ear tubes.

(When I lived with my parents, I was always sick. Antibiotics 1-2 times a month because my mother demanded them and changed doctors if she didn’t get them.)

Ob in OZ

I was ready to agree wholeheartedly, until the last line. But I assume you mean that acne usually does not require antibiotics, but when alternatives fail…

Young CC Prof

For me personally, there could be no acne dire enough to drive me to antibiotics, unless my face is actually rotting off. I suppose for some people there might be, but I still think it’s a dumb idea.

Mishimoo

That’s where it comes down to quality of life (in my opinion) – for example, if one of my kids developed cystic acne, I’d ask for a referral to a specialist for proper diagnosis and treatment including antibiotics if needed.

Young CC Prof

It’s more that I’d be afraid of the antibiotics themselves destroying my quality of life. They save lives, sure, but tetracyclines are nasty things.

Mishimoo

Oh, I know. Having seen someone struggle with cystic acne and having seen the result of tetracycline use in someone else is exactly why I’d ask for referral to a specialist.

DiomedesV

In addition to being unattractive, cystic acne can be very painful. I’ve known a couple of people who really suffered with it. But in general, I agree.

araikwao

They seem to have an anti-inflammatory effect that goes beyond the simple killing of bacteria, though

I’m with Oz – there are definitely indications for antibiotics for the scarring form of acne, which might not kill you, but can affect a person’s self-esteem life-long.

Are you nuts

Earnest, non-snarky question here – aren’t there risks to untreated ear infections? Like hearing loss? Or is that an old wives tale?

Young CC Prof

True but. Most ear infections under normal circumstances clear up on their own, and in a non-infant with a normal immune system, waiting another day or two to begin antibiotics is very unlikely to cause serious harm.

Liz Leyden

Some ear infections require antibiotics.

My college roommate had frequent ear infections as a child. They always cleared up with amoxicillin. When she was 21, she got an ear infection, and went to Health Services for antibiotics. The nurse looked in her ear, declared it “fluid” and sent her home. That Sunday, with her ear unchanged, she called her mother, a registered nurse, who asked why she hadn’t been prescribed antibiotics.

Roomie went back to Health Services Monday. Nurse looked annoyed, looked in her ear, said it was “fluid”, and told her to wait and see. That night, Roomie went to the ER. They diagnosed her with an ear infection and prescribed amoxicillin. Her ear infection cleared up within a week.

Amy M

Ugh, I was crazy sick about 3.5yr ago: pneumonia, pleurisy, sinus infection, ear infection, simultaneous. To compound the problem, my doctor at the time (he was awful) prescribed an abx that I couldn’t tolerate, so I got another one. It cleared up the pneumonia, but I still had the other infections. So I went back, he gave me ANOTHER abx I couldn’t tolerate, and kept insisting there was just fluid in my ear. Meanwhile, it was excruciating…finally, the 4th abx cleared up the other infections, but I was literally deaf in my one ear for a month, thanks to the fluid buildup while we were screwing around with abx. I got a new doctor after that.

Empliau

I too had pneumonia and pleurisy – about 9 years ago. It’s agony – for the pneumonia you need to cough, but the pleurisy makes coughing so painful. Plus, everyone thinks pleurisy is something one only gets in a Dickens novel. After a second bout of pneumonia the next year I got the pneumonia shot, even though my HMO said I was too young – luckily my PCP went to bat for me. I haven’t had pneumonia since, thankfully. Both my parents were heavy smokers (I’ve had pneumonia five or six times) so my lungs may be a little vulnerable. Thank goodness for vaccines!

On a different subject: my daughter has never had antibiotics for ear infections, but has had several courses for strep throat, always verified by culture. She seems to be prone to it, and as my mother has mitral valve trouble, probably caused by scarlet fever/rheumatic fever in the days before antibiotics, I do not mess around with strep!

Trixie

I don’t know, I had a pretty awful ear infection this winter that came on very suddenly. The only one I’ve ever had. I went to bed with a slight feeling of pressure, and by morning my eardrum had ruptured and my ear was dripping blood everywhere. They gave me the normal amount of antibiotics, it sort of helped but not much. My ear drained for weeks, until my two year old was following me around with a towel on her head too. Wasn’t until an ENT gave me a super high dose of a different antibiotic that it actually went away. No way would I go through that again on the off chance that it would go away on its own. Next time I feel that pressure, I’m going in right away before my eardrum ruptures.

Box of Salt

YCCP “waiting another day or two to begin antibiotics is very unlikely to cause serious harm.”

I’ve been reluctant to weigh on in this because I know I’m biased, but I think I do need to add my 2 cents.

Those words were spoken by someone whose toddler with a normal immune system has never had antibiotic resistant ear infections, and whose toddler’s balance was not still impacted by residual fluid for another five weeks after the third antibiotic (the second time) only eliminated the actual infection.

General recommendations are great, but please keep in mind that they are general. Each child’s specific circumstances need to be evaluated individually.

Young CC Prof

And I admit that I have bias in the opposite direction: That antibiotics are nasty toxic drugs and I’d never use them without good reason.

Other than surgical prophylaxis, I have had an allergic reaction or seriously unpleasant side effect to every antibiotic I’ve ever taken. (The two most minor of my five surgeries were done WITHOUT prophylaxis because I had too many drug allergies.) My first true allergic reaction left me wishing I could just die and get it over with for about two weeks. I couldn’t sleep or think, I was just itching.

My college roommate had permanent sinus damage because, as a child, her pediatrician gave her antibiotics for every little thing. When she did get a bacterial sinus infection, it was resistant of course, and took weeks to cure. And yet people say antibiotics might help and can’t hurt!

And antibiotic resistance scares the daylights out of me. Seriously. The problem in your daughter’s case wasn’t that antibiotic treatment was or wasn’t delayed for one day, but that it didn’t WORK for weeks.

Box of Salt

“And yet people say antibiotics might help and can’t hurt!”

I didn’t say that. I didn’t run my kids to the pedi for every little thing – in fact, I am the master of utlizing the nurse’s line to put in our records that we may have a problem, but I do I really need to drag them in just to be told “it’s probably viral: go home”?

I just wanted to point out that the flip side of “wait and see most ear infections will clear up anyway” might be a toddler who wakes up every night for more than two weeks straight pointing at an ear crying “owie.”

“Most” isn’t all, and there is a price to pay when you are not one of the “most.”

Young CC Prof

Sorry, might help won’t hurt was a quote or paraphrase from more than one doctor I’ve seen.

Box of Salt

I’m sorry you had crappy doctors.

And I will repeat:

What ticks me off about the holier-than-thou generalizations that most ear infections clear up on their own is that I know first hand (OK, second, since we’re talking about my kid) is that some of those infection DON’T.

Young CC Prof

I’m sorry. The idea that I might someday need antibiotics is so personally terrifying to me, sometimes I forget not everyone feels that way.

The Bofa, Being of the Sofa

It’s not like anyone wants antibiotics, but you know, when you walk around with elevated temp, sore throat and a cough, and the doctor says you have walking pneumonia that can be treated with a z-pack, it is absolutely a relief and I’m glad to do it.

I hope you don’t need antibiotics at any point, but there are times when they are better than the alternative. We all struggle with “when is the time to do it.” I’m sure that our doctors have erred on the side of too soon, but then again, we have also erred on the side of “should have done it sooner.”

And when my wife laid in bed with her body shaking as a result of mastitis, we weren’t going to wait around to see if she could recover on her own.

No, you don’t want to get to that point, but recognize that some of us have been there.

The Bofa, Being of the Sofa

Moreover, the suggestion that we are begging for abx for every little sniffle is really fucking offensive. Initially, we held out as long as we could, but tylenol wasn’t helping and he was too young for ibuprofen. We’d go in and see a response after the first dose.

Now, YCCP can let her children lie around miserable with a temp of a 102 all she wants, but damn it, when you see a response after 6 hrs after the first dose a couple of times, you come to the conclusion that there’s no reason waiting around the next time. By the time he was older, we could identify his symptoms of an ear infection early, and get it treated successfully, which it was.

We certainly didn’t ask for antibiotics for everything. There were a lot of things that weren’t suitable (including a bout of “cat scratch fever”) but he responded to treatment for ear infections.

As I said, I am not one to take antibiotics for everything. It took a month before I did anything about tonsillitis or walking pneumonia, hoping they would clear up on their own. I did go to dr after a month long sore throat, but we didn’t do anything until it manifested in a bump in the throat a few days later, and that cleared it up.

So in addition to the holier-than-thou generalization is the suggestion that we ask for antibiotics willy-nilly. Tell me, which of the times my kids were prescribed abx should they have not been?

Young CC Prof

Look, I hate to keep arguing with you about this, but how can oral antibiotics cure an infection in 6 hours? IV or injection, maybe, but not oral. It’s just not physically possible. When you feel much better the next day or 2 days later, THAT’s when the antibiotics are working for you.

And yes, the thought that I will probably someday need to give my child antibiotics terrifies me. I’ll do it, but I sure don’t want to.

The Bofa, Being of the Sofa

Who said cure?

No one but you.

Amy Tuteur, MD

Antibiotics should not be terrifying. Allergies to antibiotics can be terrifying but that’s an entirely different thing.

While antibiotics cannot cure anything in 6 hours, they definitely can markedly improve symptoms because the bacterial load begins decreasing, making it easier for the immune system to meet the challenge.

The war against pathogens is constantly evolving because they are constantly evolving. Even when used appropriately, they will ultimately engender antibiotic resistance and that’s why they should only be used appropriately, but their they should be used.

The Bofa, Being of the Sofa

While antibiotics cannot cure anything in 6 hours, they definitely can markedly improve symptoms because the bacterial load begins decreasing, making it easier for the immune system to meet the challenge.

And the rate of bacterial death is highest at the beginning, when the concentration is highest, so it’s not surprising to see the biggest effect at that point.

Even if it takes two days to be officially “cured” it’s not a linear progression.

Ainsley Nicholson

When you are afraid of an allergic reaction to antibiotics, it feels a lot like being afraid of the antibiotics themselves. I saw my sister almost die (and suffer permanent visual impairment) in reaction to an antibiotic her doctor perscribed. I have a short list of antibiotics that my kids and I have taken without problems in the past, and the idea of taking anything not on that list is very scary. And I avoid using the antibiotics on the short list unless I really have to.

Mac Sherbert

I forget why, but my child’s doc actually sited studies that showed that yes most ear infections will clear up on their own. However, her problem with just waiting to see if my daughter’s would clear up on it’s own was that the ear infections that didn’t clear-up had serious out comes. (Something about it spreading into the jaw bone or something…sorry I can’t remember.)
Also, as a child I had an eardrum burst due to fluid buildup from an untreated infection…So, I say treat it!

araikwao

Mastoiditis (infection of a nub of skull bone behind the ear) and I think even cerebral abscess can occur. Uncommon, but I’ve seen it.

Junebug

Yeah, my preemie got antibiotics because she had fluid in her lungs. I guess I’m crazy, but I’d rather her get 7 days of unneeded antibiotics being sure to finish the whole script than risk a full blown infection.

I don’t think the problem is so much too many scripts as it is idiots like my mom who take 3 pills then save the rest for the next time she gets sick. No matter how many times I tell her to stop doing this she insists it won’t hurt anything. Ugh.

Young CC Prof

And a preemie with fluid in the lungs is a GREAT example of a good time to use antibiotics.

Liz Leyden

Some docs are stupid about antibiotics. I developed an abcess a few years ago. I was between PCPs, so I went to Urgent Care. I expected them to lance and drain it. Instead, they prescribed antibiotics. I ended up needing minor surgery for it.

Young CC Prof

I think the moral of the story is not to go to urgent care if you want anything more complicated than an antibiotic script or an excuse note.

KarenJJ

I had a doctor prescribe antibiotics for what turned out to be a mango allergy (I got a second opinion after the itchy blisters became unbearable). I think sometimes when doctors don’t know the answer and someone is obviously miserable with some sort of lurgy it becomes a generic solution that *might* help.

Ennis Demeter

Coughs can be exhausting and some jobs are impossible to do with them. People often go the doctor out of desperation and a need for themselves or their children to rest. I don’t want unnecessary antibiotics, but I have been driven to wanting to try anything to stop a cough before.

Staceyjw

I thought the bigger issue was the routine use of antibiotics in cattle. They are used preventatively so more cows can be housed together. This is banned everywhere else, but is common here in the US.

Is this true, or just woo?

Also, I thought that only using some of the antibiotics (like, until you feel better) was much more if an issue than just getting ones you may not need. This makes sense to me, but Im no expert.

Young CC Prof

Oh, yes, animal antibiotics is a catastrophic policy. I don’t think it’s banned everywhere but the US, but the US does it the most.

For at least 25 years, we’ve known this is a terrible thing to do. No one has done bupkis to stop it.

The FDA is finally beginning to take a little bit of action, now that the horrible death toll of antibiotic-resistant infections is hitting the news. Now that it’s basically too late. Not impressed, personally.

Trixie

Yeah, I was just taking exception to the statement that no one has done anything. The FDA is doing something.

Amy Tuteur, MD

Dr. Amy Tuteur is an obstetrician gynecologist. She received her undergraduate degree from Harvard College in 1979 and her medical degree from Boston University School of Medicine in 1984. Dr. Tuteur is a former clinical instructor at Harvard Medical School. She left the practice of medicine to raise her four children. Her book, How Your Baby Is Born, an illustrated guide to pregnancy, labor and delivery was published by Ziff-Davis Press in 1994. She can be reached at DrAmy5 at aol dot com...
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